This study shows the associations between women’s reports on three measures of person-centered family planning and method continuation. It extends our understanding of how different aspects of quality are associated with method continuation. We find that when other factors are accounted for, scores on the recently validated PCFP scale are not associated with continuation. On the other hand, provider’s having a strong preference is associated with continuation. Overall, our results suggest that certain aspects of PCFP impact a woman’s likelihood of continuing her method, but, the more detailed PCFP scale either does not capture information that helps us understand how quality relates to continuation, or, person-centered quality is not a factor in women’s decision to continue using a method..
We would have expected that PCFP would be associated with continuation given the past literature. For example, a study in Kenya examining similar items found that providers giving information on side effects, seeking client preferences, interpersonal treatment of clients, and assisting with method selection were all significantly associated with an increased likelihood of current modern contraceptive use among family planning clients in five urban Kenyan cities . The effects in this study were more pronounced among younger and less educated women in their urban Kenya sample .
Our findings indicate that strong provider preference is associated with continuation. While not exactly the same outcome, other studies in India have shown discrepant results, where provider preference was not a determining influence on uptake (continuation was not measured). Specifically, a study from the Indian Council of Medical Research (ICMR) Task Force (2000) found from observations of patient-provider interaction during family planning visits at government facilities that while providers preferred Norplant for 35% of women, only 5% of clients preferred and accepted Norplant, and 60% of clients accepted IUD .
The rationale behind the inclusion of the question on provider preference in a set of questions about person-centered quality was to assess provider pressure. A strong body of work in the US has used this measure and interpreted clients reporting that the provider had a strong preference as a sign of poor quality of care [8, 16]. One study assessed predictors of implant discontinuation within first six months following insertion among family planning clients in three American cities and found that perceived pressure by a healthcare provider to choose an implant significantly predicted early implant discontinuation .
The cultural context may, however, explain the finding in India that women both wanted their providers to be more involved, and that having a provider with a strong preference for what method they adopted was associated with increased odds of method continuation. For example, it is possible that women in India want their providers to give them more advice, tell them which method they think is “right” for them, and therefore such involvement makes women feel more confident in their method choice and thus are more likely to continue. Women wanting their providers to be more involved and to express strong preferences could also be related to a societal “respect” for people who are older or of a higher social class, as is traditional in India and other Asian countries [17, 18]. Our findings are consistent with the previously cited study in Nigeria, where women who reported high ratings among other quality indicators also reported that the provider had a strong preference, suggesting that strong provider preference was an indicator of good quality .
Additionally, given India’s history of restrictive family planning programs, it is possible that women have developed cultural health capital strategies that focus less on interaction with doctors and more on providers telling women what to do . India has a long history of coercive family planning programs, and it continues to be heavily target and incentive based . This, combined with more recent evidence of women being sterilized or inserted with PPIUCDs without their knowledge or consent, highlights that the meaning and impact of “strong” provider preference is important to understand [21, 22]. Considering the socio-cultural dynamics in India, especially related to hierarchies by caste, socioeconomic status, gender, and in this case, occupation (physician/nurse interacting with a woman who is most likely a poorly educated housewife), women might feel more pressured to remain on a method if their provider showed a strong preference. In this case, “provider preference” would be an indicator of poor quality, using the framework of interpreting provider pressure and bias for specific methods.
As with other studies, this study has a number of limitations. The method mix is limited in India, with most women relying on sterilization. These women were dropped from our analysis, thus restricting our sample in India. Long acting contraceptives are limited to IUD – that is the only option given to women at India government health facilities– women who continue then are those who genuinely want to space births, and are supported by their partners/families. Additionally, many women in our sample were postpartum, thus there was high reliance on IUDs. Because of the limited sample size, we are also unable to stratify by method. Additionally, we only follow up women 6–8 weeks after they have received their family planning method. It would be interesting to see if method continuation occurred after six months or longer. Third, while we include three measures of quality, other quality measures might also be important, including counseling quality and clinical quality. Finally, sample sizes, especially among discontinuers, were small, and longer follow-up may have led to larger samples. Our analysis accounted for this rare event, but larger samples could have been beneficial.
Additionally, we are unable to account for other factors that contribute to discontinuation such as availability, side effects, and partner acceptance. Other limitations include biased estimates due to underreporting of poor care, as has been observed in other studies. Women may underreport due to social desirability or because of low expectations and acceptance of poor standards. There are also limitations from loss to follow-up in the follow-up surveys. Those who did not respond at the follow up may have done so because they had discontinued their method and did not want to report it. Finally, these data are not representative India or the districts in which data was collected, as they are based on convenience sampling approaches. However, these limitations are balanced by the strengths of this study, in that it uses a recently validated scale to measure PCFP and utilizes longitudinal data to avoid recall or other forms of bias.